9795: Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony

History: Amendment effective 07/01/2006 (Old section Here)


(a) The schedule of fees set forth in this section shall be prima facie evidence of the reasonableness of fees charged for medical-legal evaluation reports, and fees for medical-legal testimony. Reports by treating or consulting physicians, other than comprehensive, follow-up or supplemental medical-legal evaluations, regardless of whether liability for the injury has been accepted at the time the treatment was provided or the report was prepared, shall be subject to the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1 rather than to the fee schedule set forth in this section.

(b) The fee for each evaluation is calculated by multiplying the relative value by 12.50, and adding any amount applicable because of the modifiers permitted under subdivision (d). The fee for each medical-legal evaluation procedure includes reimbursement for the history and physical examination, review of records, preparation of a medical-legal report, including typing and transcription services, and overhead expenses. The complexity of the evaluation is the dominant factor determining the appropriate level of service under this section; the times to perform procedures is expected to vary due to clinical circumstances, and is therefore not the controlling factor in determining the appropriate level of service.

(c) Medical-legal evaluation reports and medical-legal testimony shall be reimbursed as follows:

CODE

B.R.

PROCEDURE DESCRIPTION: ML-100

ML100

ﾠ

Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation. This code is designed for communication purposes only. It does not imply that compensation is necessarily owed.

CODE

RV

PROCEDURE DESCRIPTION: ML-101

ML101

5

Follow-up Medical-Legal Evaluation. Limited to a follow-up medical-legal evaluation by a physician which occurs within nine months of the date on which the prior medical-legal evaluation was performed. The physician shall include in his or her report verification, under penalty of perjury, of time spent in each of the following activities: review of records, face-to-face time with the injured worker, and preparation of the report. Time spent shall be tabulated in increments of 15 minutes or portions thereof, rounded to the nearest quarter hour. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour.

CODE

RV

PROCEDURE DESCRIPTION: ML-102

ML 102

50

Basic Comprehensive Medical-Legal Evaluation. Includes all comprehensive medical-legal evaluations other than those included under ML 103 or ML 104.

CODE

RV

PROCEDURE DESCRIPTION: ML-103

ML 103

75

Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the following complexity factors: set forth below. In a separate section at the beginning of the report, the physician shall clearly and concisely specify which of the following complexity factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation. An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon:

(1) Two or more hours of face-to-face time by the physician with the injured worker;

(2) Two or more hours of record review by the physician;

(3) Two or more hours of medical research by the physician;

(4) Four or more hours spent on any combination of two complexity factors (1)-(3), which shall count as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor;

(5) Six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors;

(6) Addressing the issue of medical causation upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation;

(7) Addressing the issue of apportionment, when determination of this issue requires the physician to evaluate the claimants employment by three or more employers, three or more injuries to the same body system or body region as delineated in the Table of Contents of Guides to the Evaluation of Permanent Impairment (Fifth Edition), or two or more or more injuries involving two or more body systems or body regions as delineated in that Table of Contents. The Table of Contents of Guides to the Evaluation of Permanent Impairment (Fifth Edition), published by the American Medical Association, 2000, is incorporated by reference.

(8) Addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances;

(9) A psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.

(10) Addressing the issue of denial or modification of treatment by the claims administrator following utilization review under Labor Code section 4610.

CODE

RV

PROCEDURE DESCRIPTION: ML-104

ML 104

5

Comprehensive Medical-legal Evaluation Involving Extraordinary Circumstances. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary hourly fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician for any of the following:

(1) An evaluation which requires four or more of the complexity factors listed under ML 103; In a separate section at the beginning of the report, the physician shall clearly and concisely specify which four or more of the complexity factors were required for the evaluation, and the circumstances which made these complexity factors applicable to the evaluation. An evaluator who specifies complexity factor (3) must also provide a list of citations to the sources reviewed, and excerpt or include copies of medical evidence relied upon.

(2) An evaluation involving prior multiple injuries to the same body part or parts being evaluated, and which requires three or more of the complexity factors listed under ML 103, including three or more hours of record review by the physician;

(3) A comprehensive medical-legal evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary circumstances. When billing under this code for extraordinary circumstances, the physician shall include in his or her report (i) a clear, concise explanation of the extraordinary circumstances related to the medical condition being evaluated which justifies the use of this procedure code, and (ii) verification under penalty of perjury of the total time spent by the physician in each of these activities: reviewing the records, face-to-face time with the injured worker, preparing the report and, if applicable, any other activities.

CODE

RV

ﾠ ML-105

ML 105

5

Fees for medical-legal testimony. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician. The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of one hour for a scheduled deposition.

ML 106

5

Fees for supplemental medical-legal evaluations. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour or portion thereof, rounded to the nearest quarter hour, spent by the physician. Fees will not be allowed under this section for supplemental reports following the physician's review of (A) information which was available in the physician's office for review or was included in the medical record provided to the physician prior to preparing the initial report or (B) the results of laboratory or diagnostic tests which were ordered by the physician as part of the initial evaluation.

(d) The services described by Procedure Codes ML101 through ML 106 may be modified under the circumstances described in this subdivision. The modifying circumstances shall be identified by the addition of the appropriate modifier code, which is reported by a two-digit number placed after the usual procedure number separated by a hyphen. The modifiers available are the following:

-92 ﾠ Performed by a primary treating physician. This modifier is added solely for identification purposes, and does not change the normal value of the service.

-93 ﾠ Interpreter needed at time of examination, or other circumstances which impair communication between the physician and the injured worker and significantly increase the time needed to conduct the examination. Requires a description of the circumstance and the increased time required for the examination as a result. Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1. This modifier shall only be applicable to ML 102 and ML 103.

-94 ﾠ Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.25. If modifier -93 is also applicable, for an ML-102 or ML-103, then the value of the procedure is modified by multiplying the normal value by 1.35.

-95 ﾠ Evaluation performed by a panel selected Qualified Medical Evaluator. This modifier is added solely for identification purposes, and does not change the normal value of any procedure.

(e) Requests for duplicate reports shall be in writing. Duplicate reports shall be separately reimbursable and shall be reimbursed in the same manner as set forth in the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1.

(f) This section shall apply to medical-legal evaluation reports where the examination occurs on or after the effective date of this section. [07/01/06 - EFFECTIVE DATE] The 2006 amendments to this section shall apply to both: (1) medical-legal evaluation reports where the medical examination to which the report refers occurs on or after the effective date of the 2006 amendments; (2) medical-legal testimony provided on or after the effective date of the 2006 amendments; and (3) supplemental medical legal reports that are requested on or after the effective date of the 2006 amendments regardless of the date of the original examination.

 

OLD SCHEDULE


CCR 9795: Reasonable Level of Fees for Medical-Legal Expenses, Follow-up, Supplemental and Comprehensive Medical-Legal Evaluations and Medical-Legal Testimony. (adopted 07/16/02)

(a) The schedule of fees set forth in this section shall be prima facie evidence of the reasonableness of fees charged for medical-legal evaluation reports, and fees for medical-legal testimony. Reports by treating or consulting physicians, other than comprehensive, follow-up or supplemental medical-legal evaluations, regardless of whether liability for the injury has been accepted at the time the treatment was provided or the report was prepared, shall be subject to the Official Medical Fee Schedule adopted pursuant to Labor Code Section 5307.1 rather than to the fee schedule set forth in this section.

(b) The fee for each evaluation is calculated by multiplying the relative value by $10.00, and adding any amount applicable because of the modifiers permitted under subdivision (d). The fee for each medical-legal evaluation procedure is all inclusive, and includes reimbursement for the examination, review of records, preparation of a medical-legal report, including transcription services, and overhead expenses. The complexity of the evaluation is the dominant factor determining the appropriate level of service under this section; the times to perform procedures is expected to vary due to clinical circumstances, and is therefore not the controlling factor in determining the appropriate level of service.

(c) Medical-legal evaluation reports and medical-legal testimony shall be reimbursed as follows:

CODE - ML100
B.R.
PROCEDURE DESCRIPTION
Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation. This code is designed for communication purposes only. It does not imply that compensation is necessarily owed.

CODE - ML101
RV 5
PROCEDURE DESCRIPTION

Follow-up Medical-Legal Evaluation. Limited to a follow-up medical-legal evaluation by a physician which occurs within nine months of the date on which the prior medical-legal evaluation was performed. The physician shall include in his or her report verification, under penalty of perjury, of time spent in each of the following activities: review of records, face-to-face time with the injured worker, and preparation of the report. Time spent shall be tabulated in increments of 15 minutes or portions thereof. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary fee, whichever is less, for each quarter hour or portion thereof.

CODE - ML102
RV 50
PROCEDURE DESCRIPTION
Basic Comprehensive Medical-Legal Evaluation. Includes all comprehensive medical-legal evaluations other than those included under ML 103 or ML 104.

CODE - ML103
RV 75
PROCEDURE DESCRIPTION
Complex Comprehensive Medical-Legal Evaluation. Includes evaluations which require three of the following complexity factors: The physician shall, in a separate section at the beginning of the report, clearly and concisely specify three or more of the complexity factors listed below which were required for the evaluation and the circumstances which made these complexity factors applicable to the evaluation.
(1) two or more hours of face-to-face time by the physician with the injured worker;
(2) two or more hours of record review by the physician;
(3) two or more hours of medical research by the physician;
(4) four or more hours spent on any combination of two of the complexity factors (1)-(3), which shall count as two complexity factors. Any complexity factor in (1), (2), or (3) used to make this combination shall not also be used as the third required complexity factor;
(5) six or more hours spent on any combination of three complexity factors (1)-(3), which shall count as three complexity factors;
(6) addressing the issue of medical causation, upon written request of the party or parties requesting the report, or if a bona fide issue of medical causation is discovered in the evaluation;
(7) addressing the issue of apportionment, upon written request of the party or parties requesting the report, or if a bona fide issue of apportionment is discovered in the evaluation.
(8) addressing the issue of medical monitoring of an employee following a toxic exposure to chemical, mineral or biologic substances;
(9) a psychiatric or psychological evaluation which is the primary focus of the medical-legal evaluation.

CODE - ML104
RV 5
PROCEDURE DESCRIPTION
Comprehensive Medical-legal Evaluation Involving Extraordinary Circumstances; Medical-Legal Testimony; Supplemental Medical-Legal Evaluations. The physician shall be reimbursed at the rate of RV 5, or his or her usual and customary hourly fee, whichever is less, for each quarter hour or portion thereof spent by the physician for any of the following:
(1) Fees for comprehensive medical-legal evaluations where there are extraordinary circumstances relating to the medical condition being evaluated.
Evaluations which typically involve extraordinary circumstances include the following examples as well as evaluations of comparable complexity:
a. An evaluation which requires four or more of the complexity factors listed under ML 103;
b. An evaluation involving prior multiple injuries to the same body part or parts being evaluated, or a complex issue of medical causation, and which requires three or more of the complexity factors listed under ML 103, including three or more hours of record review by the physician;
c. An agreed medical evaluation which is obtained after each party has obtained its own evaluation, which involves complex issues of medical causation or apportionment;
d. An agreed medical evaluation for which the physician and the parties agree, prior to the evaluation, that the evaluation involves extraordinary circumstances. When billing under this code for extraordinary circumstances, the physician shall include in his or her report (i) a clear, concise explanation of the extraordinary circumstances related to the medical condition being evaluated which justifies the use of this procedure code, and (ii) verification under penalty of perjury of the total time spent by the physician in each of these activities: reviewing the records, face-to-face time with the injured worker, preparing the report and, if applicable, any other activities.
(2) Fees for medical-legal testimony. The physician shall be entitled to fees for all itemized reasonable and necessary time spent related to the testimony, including reasonable preparation and travel time. The physician shall be paid a minimum of one hour for a scheduled deposition.
(3) Fees for supplemental medical-legal evaluations. Fees will not be allowed under this section for supplemental reports following the physician's review of (A) information which was available in the physician's office for review or was included in the medical record provided to the physician prior to preparing the initial report or (B) the results of laboratory or diagnostic tests which were ordered by the physician as part of the initial evaluation.

(d) The services described by Procedure Codes ML101 through ML104 may be modified under the circumstances described in this subdivision. When applicable, the modifying circumstances should be identified by the addition of the appropriate modifier code, which is reported by a two-digit number placed after the usual procedure number separated by a hyphen. The modifiers available are the following:

-92 Performed by a primary treating physician. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by .80, except where services are performed under ML 104.

-93 Interpreter needed at time of examination, or other circumstances which impair communication between the physician and the injured worker and significantly increase the time needed to conduct the examination. Requires a description of the circumstance and the increased time required for the examination as a result. Where this modifier is applicable, the value for the procedure is modified by multiplying the normal value by 1.1. This modifier shall not be applicable to ML 101 or ML104.

-94 Evaluation and medical-legal testimony performed by an Agreed Medical Evaluator. Where this modifier is applicable, the value of the procedure is modified by multiplying the normal value by 1.25. If modifier -93 is also applicable, the value of the procedure is modified by multiplying the normal value by 1.35.

-95 Evaluation performed by a panel selected Qualified Medical Evaluator for an uncontested claim. This modifier should be added to the code reflecting the appropriate level of evaluation performed. This modifier is added solely for identification purposes, and does not change the normal value of any procedure.

-96 Modifier for medical-legal testimony. This modifier is added solely for identification purposes, and does not change the normal value of the service.

-97 Modifier for supplemental medical-legal evaluations. This modifier is added solely for identification purposes, and does not change the normal value of the procedure.

(e) Requests for duplicate reports shall be in writing. Duplicate reports shall be separately reimbursable. Where the payer requests an additional copy of the report, the payer shall reimburse for the duplicate report at $10.00 for up to the first 15 pages. Pages in excess of 15 pages shall be reimbursed at $0.25 per page.

(f) This section shall apply to medical-legal evaluation reports where the examination occurs on or after the effective date of this section. Amendments to this section shall apply to medical-legal evaluation reports where the examination to which the report refers occurs on or after the effective date of the amendments and to medical-legal testimony where such testimony occurs on or after the effective date of the amendments. The 1999 amendments to this section shall apply to medical-legal evaluation reports where the medical examination to which the report refers occurs on or after April 1, 1999, and to medical-legal testimony on or after April 1, 1999.

NOTE

Authority cited: Sections 133, 4627, 5307.3 and 5307.6, Labor Code. Reference: Sections 139.2, 4061, 4061.5, 4620, 4621, 4622, 4625, 4626, 4628 and 5307.6, Labor Code.